Consent Practices for Unrepresented Patients After Implementation of Dual-Physician Authorization in a Safety-Net Healthcare System

BACKGROUND: Unrepresented patients, those lacking decision-making capacity and an available legally authorized surrogate, experience significant ethical and clinical vulnerabilities, including delays in care and high-intensity decision-making. Physicians often assume decisional authority for these patients, yet empirical data on how institutional consent frameworks influence physician behavior are limited. OBJECTIVE: To examine changes in the frequency and types of non-emergent routine procedural consents for unrepresented patients before and after a policy shift from clergy-based consent to dual-physician authorization. DESIGN: Retrospective observational cohort study comparing procedural consent practices across two sequential 1-year periods before and after a legislative change in Texas (September 1, 2022-August 31, 2024) in a large safety-net healthcare system. PARTICIPANTS: Adult unrepresented patients were identified using procedural consent documentation as a proxy for unrepresented status. A total of 106 unrepresented patient consents were identified in the pre-policy period and 359 in the post-policy period. MAIN MEASURES: Primary outcomes included the volume and proportion of procedural consents for unrepresented patients and the frequency of specific procedures. Secondary measures included patient demographics, ICU utilization, in-hospital mortality, and ethics consultation rates. KEY RESULTS: Patients were predominantly male (74.8%-83.9%), frequently unhoused (30.2%-33.9%), and commonly required ICU care (70.3%-82.3%). Unrepresented patient consents increased from 106 of 64,694 (0.16%) in the first time period to 359 of 65,564 (0.58%) in the second time period (p < 0.0001). Renal replacement therapy consents increased from 3 to 36 (relative risk, 3.5; 95% CI, 1.11-11.28; p = 0.019). Ethics consultation was infrequent in both periods (10%-12%). CONCLUSIONS: Implementation of dual-physician authorization was associated with a significant increase in procedural consents for unrepresented patients and greater provision of renal replacement therapy. These findings suggest that consent frameworks can meaningfully influence physicians' consent practices. Health systems adopting dual-physician authorization should consider standardized ethical oversight to balance timely care with accountability and respect for patient values.